Talking about the NHS as if it is a single organisation is both inaccurate and unhelpful, writes Oz Gore, not least because it creates the impression that a cash influx can solve all ‘its’ problems. He argues that in order to keep healthcare services in national hands, we ought to first challenge the popular semantic imagination of the NHS.

We frequently hear about the NHS having a winter crisis, about the NHS failing to achieve results, about the NHS lacking in workforce, or about the NHS being privatised. It was only a few weeks ago that the NHS had its 70th birthday. This three-letter signifier features prominently at the head of news items and in the words of politicians. But where is this ‘NHS’ we speak of? Can we locate it? Can we pinpoint what this all-to-familiar acronym covers? ‘The NHS’, and perhaps because it is so rooted as an icon of the British welfare state, has become something of a linguistic black-box; a convenient denomination meant to signal the (also ephemeral) notion of ‘healthcare’.

In our research, my collegaues and I have argued that ‘The NHS’ is not so self-evident or easily articulated. From an organisational perspective, healthcare is a fragmented, convoluted terrain, which should not be treated as a single phenomenon. It is made of various organisations, at varying scales of operation and geographical footprints, working with divergent goals, and not all in communication with one another nor using the same providers to deliver services. While historically health provision was never a single, monolithic operation, this was exacerbated in 2012 with the enactment of the Health and Social Care Act, a reform described as ‘so big it can be seen from space’. The complexity and diversity of organisations introduced by the Act now means that it is extremely difficult to generalise about health provision in England.

In particular, the question of whether ‘The NHS’ is privatised becomes almost nonsensical when taking into account the complexity of how health is administered. Take, for example, General Practitioners (GPs). The local practice is where one goes to for healthcare in England, be it for advice, referral, treatment, or medication. And it is, most broadly, truly free. This encounter with ‘The NHS’ is in many respects a false encounter, because these practices are private businesses. While practitioners might all wear NHS tags on their clothes and have NHS branding on their buildings, thus reinforcing a popular imagination of a single organisation, these partnerships or ‘single handled’ practices are contractors with government, comprising their own set of concerns and aspirations. From a regulatory and legal perspective, and even though these GPs act as the first and most available point of contact with the public, they are not public employees. My local practice, and all other ones, are not branches of the NHS. Instead of employees of a national not-for-profit service, under the model opted for back in 1948, their services are bought by the government in bulk based on a collective contract.

GPs are but one example of the organisational disparities within the so-called ‘system’, with hospitals, care homes, and a plethora of other providers working under their own regulatory and contractual obligations while undergoing divergent reforms. It is an organisational mess, made worse by the Health and Social Care Act, which means there is not always a firm foundation upon which to form a position on the political question of privatisation. The answer would be yes if we focus on how private companies are providing health services. It might be no if we focus on public expenditure on services or how these GPs are collectively contracted. Either way, when taking this kind of diversity into account, the designator ‘the NHS’ is not very helpful.

‘The NHS’ black-box and the niceties of an acronym make it easier to cherry-pick politically-oriented evidence, and harder for the public to maintain a grip on what is happening in their respective constituencies. Indeed, delving into such details is a privileged practice, highly restricted to those with time and expertise. Nonetheless, colloquial and everyday discussions on health in England would benefit from a closer look at where and what we mean when we invoke ‘the NHS’ in political argumentation or news headlines. Speaking of ‘The NHS’ makes it much easier to claim that money will go ‘there’, as did the VoteLeave campaign or Theresa May with her recent promises of a ‘£20b birthday present to the NHS’.

MPs on both the left and the right talk of ‘The NHS’ in a similar way. However, this sort of political language is potentially much more useful for those wishing to further diminish national expenditure on health than for those hoping to restore it. Talking about ‘the NHS’ fuels an imagination of a seemingly unified welfare state which MPs can be seen to pay lip service to while introducing far-reaching change. Under the last two Conservative-led governments, healthcare in England has seen fundamental reconfiguration of working relations for practitioners, of the governance of services and of the kind of accountability the public can expect. For example, more and more GPs are now grouped into ‘Superpractices’ aimed at cost savings and at achieving a mythical ‘Care at Scale’ with questionable impact on health outcomes and equity, and little in the way of ‘system’ level governance to guide, support, and regulate this experimentation. These issues remain under the radar when we continue to speak of ‘The NHS’ as if it is a simple organisation, a system or a thing, ready for a cash influx that can solve its problems. Worse still, it risks us buying into and reinforcing political marketing designed to create an image of wholeness, unity, and a ‘national’ health service provision.

‘The NHS’, in a sense, is everywhere. It is at local practices, on newspaper pages, in political arguments, or in the fleeting encounter with an ambulance on the high street. In another sense, this monolithic creature, ‘The NHS’, is nowhere in reality. To be more real about what is at stake, it is necessary to change the conversation, in order to focus on the specificities of decision-making armed with the needed contextual information to understand its implications (is it local? national? by private bodies contracted by government? by government employees?).

It would be extremely helpful for news outlets to more often name the organisation and localities at stake directly in headlines and titles, rather than the omnipresent ‘NHS’. Perhaps a more radical approach would be to stop speaking of the NHS altogether, and talk about the specificities of medicines, surgeries, and treatments. The forms of how to do this are plenty and context dependant, but we need to sidestep a popular imagination of a single organisation, a mighty ‘NHS’ that does things and has things happen to it. This is particularly so as we are approaching the crunch time of the Brexit negotiations, and the future of ‘The NHS’ will feature prominently in any attempt to justify or oppose future relations with Europe and subsequent trade-deals, especially with the privatisation minded United States.

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Note: the above draws on the author’s work (with Jonathan Hammond, Simon Bailey, Katherine Checkland & Damian Hodgson) published in Public Management Review.

About the Author

Oz Gore is Lecturer in Innovation, Technology and Operations in the School of Business at the University of Leicester.

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.Featured image credit: Pixabay (Public Domain).

Interesting and thought-provoking piece. However, I’d question a couple of the assumptions. For example, the argument that “more and more GPs are now grouped into ‘Superpractices’ aimed at cost savings and at achieving a mythical ‘Care at Scale’ with questionable impact on health outcomes and equity” is perhaps a little over-simplified & one-dimensional. The problems in recruting and retaining GPs is well-documented, as is the fact that many younger GPs just aren’t drawn to the traditional GP Partner model. Likewise, there’s clear evidence on the value of a larger multi-disciplinary team in primary care, enabling better use of non-GP staff in supporting patients and sharing skills across larger primary care patient populations. That’s not ‘mythical’, it’s evidenced. Nor is it just about cost savings; it’s about practically recognising & responding to changes & challenges in the workforce and the developing nature of clinical skills.

Thank you for your great comment! I agree that ‘Care at Scale’ might be susceptible to the same problems of the NHS signifier, and, indeed, oversimplified. For instance, it erases a discussion over which ‘Care at Scale’ – the one of the super-practices or the one of the GP Federations? I am totally with you that it is a one-dimensional reference.

As for the myth of scale, I take myth to be more than just ‘not-evidenced’. But to your point about the none existence of credible evidence – that is my experience. If you’re interested, here’s a systematic review on how scale impacts delivery. They claim good evidence is scarce (available here: https://bjgp.org/content/early/2018/02/12/bjgp18X694997). I currently see ‘Care at Scale’ as a rationalized myth, one that speaks to a supposed commonsense of economies of scale rather than to an application of a well thought-out, validated model. It might be that delivery on larger scales turns out to be better, but I believe it is hard to maintain its current adoption is driven by evidence.

Thank you for pointing out the GPOnline article – it’s an interesting one! From the perspective of evidence, I’d scrutinize how it is a super-practice that announces these results. But regardless, what is claimed to be boosting continuity of care is actually the reduction of patient populations. To me, it’s telling of the confusion surrounding how to evidence the relationship between organisational scale and primary care and around how to pinpoint what might be a ‘best practice’ in this regard.

The NHS has been set up for privatisation by successive governments since 1990 this is due entirely because EU procurement regulations require it to be privatised, the nonsense about leaving the EU leaving us open to American predatory health care providers is obtuse as remaining in the EU would have ensured it.

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